Impact of dietetic CEDS-led acute admissions

1. Shortly after North Cumbria’s community eating disorder service was launched, they were informed that their closest specialist eating disorder unit was closing, meaning there was a requirement to keep young people and their families closer to home and prevent avoidable admissions.
2. Practitioners believed that they lacked the skills and time to manage an acute admission leading to handing over patient care. Similarly, ward sta felt under-skilled to manage mental health presentations and too over-burdened by other demands to manage crucial care aspects, like supported mealtimes. Acute dietetic colleagues felt equally under-skilled and resourced in the challenges of mental health care, feeling unable to ensure adequate time was given to personalised eating disorder meal plans.
3. Any MDT role could support a family through admission, but the team championed the community eating disorder dietetic role as the key driver for change. Eating disorder dietitians are uniquely able to tie together the core transdiagnostic eating disorder domains: medical, nutritional and psychological management.

Like so many other services, following the release of the access and waiting times (AWT) standard for eating disorders (ED) (NHS-E, 2015), North Cumbria’s community ED service (CEDS) for children and young people (CYP) opened in January 2019. Somewhat uniquely, however, the conception and management of the multidisciplinary (MDT) service was dietetic- and psychology-led.

A dietitian was the operational and clinical lead, with a clinical psychologist being the psychological therapy lead. The clinicians employed into CEDS all had specialist ED experience from working in generic child and adolescent mental health services (CAMHS). As such, our practitioners’ collective inherited culture was one in which we routinely used Specialist Eating Disorder Units (SEDUs) during acuity, often for long durations and always over 1.5 hours travel time each way from a patient’s home. 

This culture was echoed by the local acute team. Our prior experience of any acute ED admission was that most were not accepted, few were understood, and treatment was ineffective at avoiding a long admission. Discharges were pushed either into a SEDU or back into the community, often prematurely and with ongoing risks. 

Only weeks into our CEDS service launch we were informed that our closest SEDU was closing. Our psychiatric inpatient option was a general mental health ward or an SEDU more than three hours away from a patient’s home. Coupled with the evidence regarding outcomes from care pathways (House et al., 2012) the bottom line was clear: keep young people and their families closer to home and prevent avoidable admissions.

But, how?

The problems within CEDS’ own culture were evident. Our practitioners also believed that they lacked the skills and time to manage an acute admission leading to handing over patient care. Similarly, ward staff felt under-skilled to manage mental health presentations and too over-burdened by other demands to manage crucial care aspects, like supported mealtimes. Acute dietetic colleagues felt equally under-skilled and resourced in the challenges of mental health care, feeling unable to ensure adequate time was given to personalised ED meal plans.

These three-fold contributing dialogues meant that parents and patients – who were at their most unwell and vulnerable – felt underconfident in the help they received, frequently hearing, either directly or by inference, that “they didn’t belong here” –  a misnomer which stems from an understandable place of concern but which may be indirectly discriminatory. A sentiment that CEDS too contributed to. This created a unified voice and a total system culture that placed treatment emphasis in SEDUs and away from home.

Countertransference in mental health is understood as the reflection of unhelpful behaviour patterns from a patient/family into a team (Satir et al., 2009). However, we can use reflective behaviour helpfully, by applying aspects of a clinical treatment model into how a treating team functions and operates. Our highest-grade evidence-based treatment model for CYP with anorexia nervosa is a treatment called Family Therapy for Anorexia Nervosa (FT-AN) (NICE, 2017). Consequently, teams which are able to use a systemic (whole system) based lens to explore problems can find more helpful and effective solutions (WHO, 2009). 

Systemic team culture starts with understanding our role in the maintenance of the status quo. It is essential not to fall into the trap of placing the problem at, or within, another team or person. Ergo: avoiding the common trap of seeing the admission barriers as simply a skills, knowledge or capacity deficit of the acute team  Thinking systemically showed us that the status quo was being maintained by  everyone in the system: our team, the ward team, the patient and their family (Fig. 1).

When modelled in this way, it becomes clear that delivering training in isolation, as is usually considered the solution, would not adequately deliver change. What we needed instead, was to break the cycle of maintenance resistance in multiple, meaningful ways. 

Fig. 1

We referred to our core FT-AN treatment model to shape our approach again. This model is explicit in the need to empower parents and families in the feeding and support of their young people. It is also explicit in the helpfulness of identifying and raising appropriate early parental concern. When this raised parental anxiety is met with confident experts, who also provide parental skills coaching, it becomes empowering. It enables a care team to come alongside the anxiety of a caregiver and to support them through it, rather than joining the anxiety. What we knew from our maintenance cycle was that we were strongly creating the opposite of this: we were disempowering and disabling parents. 

Therefore, instead of offering training and scaffolding to an overstretched, underconfident workforce and expecting a different outcome, we made the decision to step in.

Exploring aligning guidance about care management, AWT (NHS-E, 2015) notes that: “It is key that throughout the eating disorders pathway the CEDS-CYP provides oversight, support and consultation […..] even if not directly involved in providing all aspects of treatment”; “a detailed written plan should be established between the CEDS-CYP team and the other treating team” and “The CEDS-CYP should have a strong link with inpatient services, the purpose of which will be to allow for brief admissions”. 

In considering this, we saw our expert role as extending to their new care setting. We consequently changed our way of working in several ways to break in this maintenance cycle:

Breaking maintaining points 2, 5 and 6

1. As a team, we completed a comprehensive MDT assessment which was structured around FT-AN before admission, or on the ward. This gave us all the information we needed, framed around the treatment model for continuity.
2. Rather than seeing an acute stay as a break in therapeutic continuity, this FT-AN assessment and approach was used throughout admission. Using this model, we empowered parents to stay with their child throughout the admission with the role to support mealtimes. This took the task of supported mealtimes away from under-confident staff , which reduced pressure and expectation on them. Crucially, it also allowed the YP to experience consistent, boundaried care, focused on recovery from anorexia. It gave parents the chance to practise difficult feeding skills in a safe environment. It moved parents from “we can’t do this at home” to “we can go home now; we know how to do this”.
3. CEDS then stepped in as experts to devise the specific ED feeding and management plan. This allowed parents to feel confident in the expert care that their child was receiving. It also enabled CEDS to hold responsibility for ‘hard messages’ and unwelcome boundaries (like calorie requirements, behaviour management, consequences, risk and monitoring). Doing this meant that parents could hold only the supportive care giver role that was appropriate to them, while we also developed their skills in tolerating the inevitable anorexic pushback

Breaking maintaining points 1 and 2

1. As leaders, we steadfastly listened to our CEDS staff  in their hesitations and concerns. We empowered them with skills and knowledge where they felt there were gaps and used team members with more ward knowledge in this capacity. A significant part of this was the emphasis on dietetics as a transdiagnostic role best able to support this objective (see the role of the dietitian below)
2. Where there was concern about managing impacts on the rest of the caseload, we integrated the whole team into this model to provide support. We also invested in talent management – identifying who had more experience or interest in developing acute support and strengthening this
3. During an admission, we accepted the intensity (despite this not being explicitly commissioned) that CEDS staff  would attend the ward approximately three times per week and provide additional phone support for any admission.

Creating breaks at points 2, 3, 4 and 5

1. Rather than provide scaffolding and training, CEDS dietitians took the lead on individualised re-feeding and management plans on the acute ward, supported plan reviews and discharges. Our systems knowledge (nutrition support contracts, catering provisions, tube feeding policy etc.) were kept up to date by the acute dietetic team who were hugely accommodating to any queries, requests and partnership working
2. CEDS-led management plans were co-managed with medical/nursing teams, fully patient/family-informed and individualised and followed the NICE treatment model. This avoided mixed messages, ambiguity or a delay in therapeutic care. 

The maintenance cycle was broken

Our CEDS team frequently reflected on the challenges and positives of this way of working. We openly 
discussed the hardships and intensity, while focusing on the positives. This included our patient and family feedback, reduced Tier 4 admissions and achieved operational objectives. Consequently, we changed the team dialogue that ‘ED patients needed to be treated in SEDUs’ and created a whole-system culture that valued acute co-working admissions.

From 1 of April 2020 to 31 March 2021 (Fig.2)

• 15 patients required acute admission (300% increase from the previous year)
• All 15 avoided Tier 4 admission 
• Longest duration: 47 days 
• Average duration: 12 days
• Total acute bed days: 177

Fig. 2

From 1 April 2021 to 31 March 2022 (Fig. 3)

• 10 patients required acute admission (50% decrease from previous year)
• All 10 avoided Tier 4 admission 
• Longest duration: 60 days* 
• Average duration: 21.9 days*
• Total acute bed days: 219 (24% increase from previous year)*
• There was an agreement that an expected minimum duration of safe stay for an acute re-feeding admission was routinely considered as 10 days. This set helpful expectations for the system at the start of an admission.

* Figures are impacted by two complex admissions with co-occurring autism, avoidant restrictive food intake disorder and social care challenges. 

Fig. 3

Despite not being explicitly commissioned to provide an intensive home-treatment service, North Cumbria CEDS successfully kept almost all their CYP out of hospital and with their families. The first year of reduced tier 4 bed stays represented a cost saving impact to the trust of £537,474, with an additional £399,202 in year two (Fig.4). 

Fig. 4

Whilst any of our CEDS MDT roles could support a family through admission, we championed the CEDS dietetic role as the key driver for this system change. ED dietitians are uniquely able to tie together the core transdiagnostic ED domains: medical, nutritional and psychological management (Falcoski et al., 2024). Although the primary focus of acute re-feeding admissions is to reverse malnutrition and its associated complications (Garber et al., 2016), a maintained therapeutic framework is highly advantageous.

Our acute dietetic colleagues are highly skilled clinicians, capable and qualified to determine safe re-feeding plans, especially if they are supported to apply MEED (RCP, 2023) guidance. However, acute dietitians understandably lack the therapeutic ED experience relating to holistic treatment aspects. 

For example, lacking confidence and experience in understanding safe and unsafe nutritional negotiations; understanding ED risk nuance; counselling parents on ED behaviour observations; determining mealtime durations and replacements; considering supervision, bathroom access, compensatory behaviours etc. 

Similarly, our MDT CEDS practitioners could advise on all therapeutic and parent-skill aspects, but most lacked medical confidence and all were unable to advise on the specialised re-feeding plan. The ED dietitian is the only clinician able to bridge these domains. Given that a lack of collaboration causes confusion, adds to patient burden and potentially delays recovery (NHS-E, 2015), it is important to reduce any potential for fragmentation or miscommunication. 

Our acute dietetic colleagues are highly skilled clinicians capable and qualified  to determine safe re-feeding plans.

A skilled understanding of nutritional and malnutrition science, held concurrently with psychological and behaviour change skills, positions ED dietetic expertise as integral (Jeffrey and Heruc, 2020). Not only is it risk adverse, but the ability to respond across transdiagnostic domains is a key component in patient activation. This means demonstrable improvements in the family’s knowledge, skills and confidence in managing the ED. The evidenced lack of long-term admissions parallels literature consensus on the importance of patient activation in health outcomes and cost savings (Hibbard et al., 2004): a significant contributor to its success. 

Reciprocity is grounded in the science of influence (Falb and Yukl, 1992). We accepted that there was a need to support more, take a bigger lead on any codeveloped resources, and demonstrate responsivity and presence before seeing returns. Equally, we allowed ourselves to be criticised – bearing the brunt of years of frustration and poorly orchestrated co-working tensions. We saw the helpful expertise of all involved, as well as the criticisms of a system-wide problem. Our treatment models ask families to be vulnerable and to re-learn helpful behaviours and so we asked the same of ourselves. 

Interestingly, we didn’t deliver any training to the acute wards. We had observed that delivering training to a reluctant team increased their perception of demand and in turn their resistance to learning. Instead, training occurred frequently in the form of indirect learning from reciprocity and observation. Learning by apprentice osmosis led to improvements in ED acute care across the board in a far less challenging way. 

From a starting position of no special-interest paediatrician, reluctant admissions with risky early discharges and a strong push to SEDU, over two years this reciprocity approach led to:

1. The development of a service level agreement (SLA) which identified two special interest pediatricians from our two local hospitals. This enabled integrated monthly paediatric time within our monthly complex cases team meetings
2. The development of a pathway for rapid access and non-urgent advice for all community ED patients into paediatric outpatient clinics
3. The identification of a ward-based ED nurse champion
4. The development of shared resources and learning
5. Improved respectful communication during times of pressure or conflict. The system was quick to be open about shared challenges and problem solving 
6. CEDS clinical expertise was respected, leading to acute admissions being accepted on request and the duration of admission co-determined
7. The agreement that a CEDS patients could be admitted to the paediatric ward up to age 17 (usual ceiling was age 16)

Learning by apprentice-osmosis led to improvements in ED acute care across the board in a far less challenging way.

Our main challenges included a lack of direct commissioning to work in this way, alongside managing what is inherently an inconsistent, short-term and intensive resource demand. This is particularly true for the dietetic workforce, who need strong independent skills in caseload and risk management with a corresponding level of ED expertise reflected in pay banding. The CEDS team did also struggle to manage expectations of support during staffing challenges (such as periods of sickness and leave). Into year two, we were able to draw down on some of our tier 4 savings and redirect this into our dietetic workforce to support this demand. 

Overcoming the challenges of historic poor working, criticism of CAMHS and accepting reciprocity demand was difficult and required leadership guidance, but  was not insurmountable. 

Overall, such early CEDS-led intensity reduced secondary crisis management and represented a 
treatment duration cost reduction. It was also highly regarded by the clinical teams and supported job satisfaction. 

This article evaluates an initiative from January 2019 to December 2022. Whether this is a solution for the future depends on questions about sustainability, such as how specialist skills and current resources are mobilised to their highest effectiveness, what remains as a gap thereafter and how flexible services are maintained. 

A lack of workforce agility can be argued as a limiting factor in NHS productivity (Horton et al., 2021), and the potential breadth of the allied health professional scope (NHS-E, 2017), and the dietetic role in ED treatment remains vast but underutilised (Falcoski et al., 2024). National policy continues to reference the need to consider flexible, responsive services which promote expertise which follows the patient and seeks a reduction in tier 4 admissions (2024 draft CYPS commissioning guidance; NHS-E, 2015). NCCMH Legislation (NHS, 2019) additionally notes that “The CED service should act as the lead in providing care for [CYP] presenting with an eating disorder, even if they are also receiving inpatient care”. Consequently, I believe CEDS, and specifically ED dietetic in-reach, should be considered as part of a talent development strategy which meets these needs. Local CEDS and dietetic teams could explore this through consideration of: 

• Shared care or service level agreements
• Joint funded MEED dietitian posts held between acute and mental health teams 
• The specialist development of champions or special interest ED acute dietitians who have access to mental health team training, supervision and peer support
• Supporting the development of dedicated dietetic posts/time within effective liaison teams

We didn’t want to go to hospital at all, but we definitely didn’t want our daughter to be so far away from us for so long. It really wouldn’t have been the right thing to do to separate her from us. – Carer

Although it was hard and we annoyed each other at times, I can’t say enough how pleased I am that this [SEDU admission] didn’t happen. I was surprised we got home so quickly actually. – Carer

I was in hospital for three weeks … it was so hard but I always felt like at least I knew what was going on with my food and the plan… I was so lucky that my parents stayed with me too. I can’t imagine doing this with people I didn’t know. You really have saved my life. – Patient

When our patients are on the ward, seeing the specialist dietitian is probably the single most impactful thing for turning things around at that time. – CEDS MDT Member

In over three years, I have never received feedback from families or colleagues, in both acute and community settings, to say they wish a CEDS dietitian hadn’t been directly involved in their admission.  – ED Dietitian

The CEDS team, and especially their dietitians, are so helpful to the ward staff when they require support and advice. [They] are an imperative and valued service within our trust and we are proud to have such a good collaborative working relationship.  – Acute Ward Matron

In general paediatric dietetics, we often negotiate dietetic goals with [CYP], whereas in eating disorder dietetics there are often limited negotiations. We each have a unique set of skills… These admissions can be complex and there may be other factors involved… We work together to ensure that needs are met.  – Paediatric dietitian